Integrating the DIEP and muscle-sparing (MS-2) free TRAM techniques optimizes surgical outcomes: Presentation of an algorithm for microsurgical breast reconstruction based on perforator anatomy

Background: Optimal surgical outcomes in autogenous breast reconstruction require a balance between the reliability of older transverse rectus abdominis musculocutaneous (TRAM) flap techniques and the decreased donor-site morbidity of the newer deep inferior epigastric perforator (DIEP) flap techniques. This article presents an approach to autogenous breast reconstruction that uses principles of both techniques. Methods: One hundred twenty patients receiving 140 breast reconstructions (100 unilateral and 20 bilateral) using the DIEP or the muscle-sparing (MS-2) free TRAM techniques were retrospectively reviewed over a 5-year period. All patients before January of 2004 (group 1, n = 107 flaps) received the DIEP flap. Patients after January of 2004 (group 2, n = 33 flaps) were approached using an integrated technique and received either the DIEP or the muscle-sparing (MS-2) free TRAM based on the perforator anatomy identified at the time of surgery. Results: Average follow-up was 27 months for group 1 (range, 5.2 to 43 months) and 8 months for group 2 (range, 3 to 18 months). By applying the surgical technique according to the algorithm presented, the success rate has been increased to 100 percent (33 of 33 flaps, p = 0.0425, group 2) over the past 18 months without increasing donor-site morbidity. This compares with a success rate of only 92 percent (98 of 107 flaps, group 1) when the DIEP was attempted nonselectively in every case. Conclusion: By integrating DIEP and MS-2 surgical techniques and selectively applying the surgical technique according to the perforator anatomy, microsurgical breast reconstruction can be more reliably offered to patients while still minimizing donor-site morbidity.